Tuesday, 7 June 2011

Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous fortune,

Or to take arms against a sea of troubles, and by opposing end them? – Shakespeare

A useful way to approach problems of anger, anxiety and depression is to see them not so much as separate issues, but as different kinds of response to ongoing frustration of the achievement of our goals, and to the sense of threat, stress and pressure that this brings. They are all potentially adaptive responses, as they are based on the evolved fight/flight/freeze system, but of course they can also be maladaptive.

Let’s think about them first from an emotional/behavioural point of view. We will look more closely further down at the cognitive themes which these feelings and behaviours would suggest.

Ongoing frustration of important goals, for instance failure to secure a job despite our best efforts, can first of all make us feel angry, but we don’t necessarily feel very fearful or demotivated yet. The anger we feel can give us energy for the fight, and determination not to be beaten. Of course it may also make us irritable and demanding, which may not help the situation.

Continued efforts without improvement may begin to frighten us – we start to sense that further fight may bring no change in our situation, and we may begin to feel threatened, to feel that our goals are really in danger. This can make us understandably very anxious, especially if these goals are fairly fundamental ones, such as making enough money to live, protecting our children, keeping ourselves healthy, hanging on to an important relationship etc. Again, these feelings can be adaptive, by helping us to be cautious and realistic, or they may just undermine our faith in our ability to cope, especially as we become more and more conscious of the fact that we are anxious. In the anxious state, however, we still feel some hope along with the doubt, feeling at least some of the time that it is worth while trying to re-engage with the struggle. We feel like running away, and may indeed do so some of the time, but we don’t give up completely.

If we lose this thread of hope, feeling that the struggle is no longer worth it, we find ourselves in the depressed state. This is the frozen, numb state, where caring about anything seems futile (as it seems like it cannot be achieved anyway), and any signs of hope, or even of success, are dismissed as illusory. We therefore don’t really try anymore, further reinforcing our lack of goal achievement. This is generally seen as a maladaptive state, and its possible adaptive function is less clear, but it may be

•An evolved mechanism of distress telling us to hibernate, escape or change something

•A signal that our coping system is overwhelmed and that we need time out

As I mentioned above, it is interesting to look at these three states from a cognitive perspective, as Beck does (e.g. Beck, A.T., 1976, Cognitive Therapy and the Emotional Disorders. New York: International Universities Press). The thinking described here may of course be realistic or unrealistic, functional or dysfunctional, to whatever degree.

Cognitively, the angry state reflects themes of perceived offense/transgression, rooting itself in the belief that something is wrong, unjust, unfair, and needs to be put right. Angry thinking and self-talk are characterised by phrases such as “should”, “ought”, “no right to”, “fault”, etc.

In the shift to the anxious state, we still see things as being wrong in some way, but we begin to see some aspect or aspects of the situation as more dangerous/threatening than we did, and our ability to cope with it as being less than we did. There is still a sense of defensiveness, but along with it a greater sense of vulnerability, and therefore our self-talk becomes less like fighting talk, and more safety-oriented: “what if?”, “I’d best not”, “I might fail” etc.

If the angry state is characterised by the view that some bad outcome shouldn’t happen, and the anxious state by the view that it looks as if it might happen despite our best efforts, then the depressed state sees it as having happened, actual loss rather than threatened loss, actual failure rather than possible failure. Furthermore, the depressed person can see no likely change to that situation, so their perspective is also one of futility; effort seems pointless, as there appears to be no real prospect of any significant action being rewarding.

Of course, there are ways out of this state, and they involve the reversal of the path we have just traced.

If efforts are to be made by the depressed person, especially in the important areas of life where they have experienced such disappointment and frustration, then these efforts need to be ones which lead to some feeling of reward (CBT therefore always starts with small, doable yet significant activities, such as getting a little bit of fresh air and exercise).

As a person begins to feel less depressed, and starts to look at their world again as maybe being a place of possibility rather than impossibility, the possibility of things going wrong again looms for them, and it is very common to move from depression back into anxiety. This is so uncomfortable that it can send many people back to depression again, so the therapist needs to make sure the client is ready for this, and help them shift the focus of the therapeutic work to the different themes of this state.

What is less obvious to many people is that if they are to re-engage with the life issues which were causing them so much stress, they may well need to revisit the angry state. This is normal, but it may need to be normalised for some clients. There may be dysfunctional expectations involved in their anger, and these may need to be worked on, along with learning more assertive ways of approaching life challenges. But there is also potentially useful energy in the angry state, and we may need to be reminded that anger is often a valid emotion if we are to step into the sea of troubles once again.

Tuesday, 3 May 2011

The 5 Levels of Integrative CBT outlined in these blogs can be a useful tool for reviewing where therapy is going, especially if it is stuck. This is something a therapist can carry out in their own mind as they reflect before and after sessions; it can also take place as an explicit discussion between therapist and client; or it can happen, of course, in supervision, which can make Integrative CBT another useful model for supervisors.

Level 1:

This is the primarily Relational level, where the focus is on immediacy of contact and connection with self, therapist, and others.

Useful review questions on this level are:

How solid is the therapist-client contact? Has it been well-established to start with? Does it need to be revisited/re-established?

How solid is the client’s contact with themselves? Can they access relevant feelings?

What practical issues in the client’s life/environment may be in need of more attention than they are getting?

Does there need to be a review of goals? Of resources? Of motivation?

Are there skills such as assertiveness or relaxation that the client is in need of in order to move ahead?

Often this is the most important level to come back to when therapy doesn’t seem to be progressing. It may be that a clear sense of direction has been lost – goals, targets, strategies, commitments may need to be revisited, and even revised if necessary.

Level 3:

This is the level of Cognitive-Emotional Re-Learning.

Useful review questions on this level are:

What blocks to therapeutic progress have arisen at Level 2 which might suggest that particular vicious cycles may be in operation? Do any of them suggest a specific mental health diagnosis such as depression, an anxiety disorder, an addiction, etc?

What aspects of a cognitively-based case formulation need to be put in place/revisited?

Are there specific negative automatic thoughts or cognitive distortions in play that haven’t been identified yet? Specific safety behaviours?

Often what needs reviewing at this level is the case formulation, and sometimes what needs to come more clearly into focus is an “off-the-shelf” case formulation, in other words a diagnosis. Sometime the reason that clients cannot make the necessary changes at a problem-solving level, despite their best efforts, is that they are struggling within a particular pattern of vicious cycles between specific cognitions, behaviours and emotions; sometimes this pattern already has a name e.g. Social Anxiety, Depression, Alcohol Dependence. If this is the case, there will not be much progress until both client and therapist become clear about it.

Level 4:

This is the level of Schema Change.

Useful review questions on this level are:

Is it necessary/desirable for the therapeutic work to go deeper, to address schemas/core beliefs?

How clearly named are the relevant schemas/core beliefs? Would a Young Schema Questionnaire be useful?

At the very least, more explicit exploration and naming of schemas/core beliefs can help to pull together a coherent case formulation. Deeper healing and resistance to relapse can also come from more direct work on softening/diluting the power of maladaptive schemas – however, this is long-term work by its very nature, and clients may need to make a difficult decision about the trade-off between investing further in therapy, and getting on with the improvements they have gained.

Which of the client’s needs can perhaps be more fully met, and which ones are more a matter of adjusting their expectations to reality?

Does the client need to look more closely at the values/philosophy they hold, in order to get a clearer perspective on their larger goals?

Reviewing at this level can be surprisingly practical, and not as abstract as it might sound. There is very little point putting great effort into moving forward, if you aren’t facing in the direction in which you want to go!

Thursday, 7 April 2011

The concept of Safety Behaviours (or Safety-Seeking Behaviours) is a familiar one to those working with anxiety from a CBT perspective.

According to David M. Clark (1999),

Salkovskis (1988, 1991) defined a safety-seeking behaviour as ``a behaviour which is performed in order to prevent or minimise a feared catastrophe'' and suggested that such behaviours often explain why the non-occurrence of a feared event fails to change patients' negative beliefs. For example, in the case of cardiac concerned panic patients, he suggested that they continue to think that they might die in a panic attack because every time they have panic attacks, they sit down, rest, slow down their breathing or engage in some other safety-seeking behaviour and believe, erroneously, that performing the behaviour is the only reason they did not die.

Clark goes on to give the following examples of safety behaviours associated with a patient's fear of blushing. First he describes the feared outcome, then the safety behaviours intended to prevent that outcome:

The key disadvantage of safety behaviours, of course, is that they prevent disconfirmation of catastrophic beliefs, by making sure that they don’t get tested against reality. We never find out what would happen if we didn’t cover up the blush, if we said what we really think, if we drank from a cup someone else had touched.

Over their lifetimes, anxiety sufferers often engage in broader strategies of safety-seeking, which simply become part of their lifestyle. A socially anxious person, for instance, may choose their hobbies, their friends, even their spouse, in a way which is designed to protect themselves from social danger (i.e. negative judgment). Their hobbies may be solitary, their friends may be undemanding and task-oriented, their spouse may be happy to mostly stay at home and to concentrate on the domestic side of their lives.

Joining a religious group may also be a tempting safety-seeking strategy for some people, as there is usually a strong focus on group-belonging, and on directing negative judgments at people outside the group rather than within it.

The workaholic high-achiever, to take another example, seems to have found a way to guarantee positive rather than negative judgments from their peers.Of course, like all such strategies, this tends only to work in the short-term, bringing other problems in the longer-term, such as damage to family relationships, burnout etc. On the other side of the coin, the stay-at-home example above may also lead to its own negative career consequences, due to poor social networking skills etc.

There is food for thought here: to the extent that any of us are socially anxious and feel the need to ward off negative judgment, how much may we have built our lifestyles around this need?

Finally, widespread safety behaviours can also be found outside of these more individual examples. Superstitious behaviours, which are very common in most human populations, are classic examples of safety behaviours: touching wood is definitely ``a behaviour which is performed in order to prevent or minimise a feared catastrophe'', as is avoiding the number 13, and so many other everyday superstitious behaviours.

Perhaps the concept of Safety Behaviours needs to be a familiar one to all of us, and not just those working with anxiety…

Friday, 25 March 2011

Judith Beck (1995, p. 1) defines the Cognitive Model of emotional disorders as follows: “…the cognitive model proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances.”

There are many misunderstandings about the role of cognition in psychotherapy, for example:

The notion that cognition is disconnected from emotion. The reality is that, except in the case of specifically abstract thought, they are intimately connected – think of the panic that instantly accompanies the thought/belief “I’m having a heart attack”.

The notion that working with cognition is somehow optional in psychotherapy practice. In fact, given that the term “cognition” refers to something very central to human experience, namely the constant processing of information that informs our responses to our world, it should feature very strongly as a focus for therapeutic change. As Aaron Beck has remarked, "If beliefs do not change, there is no improvement. If beliefs change, symptoms change.” (American Psychological Association, 108th Convention, Washington DC, August 4-8, 2000).

However, the misunderstanding I mainly want to explore in this month’s blog is the idea that cognition is superficial and shallow. The truth is that it is deep and multi-layered; below I describe the various layers where we can see cognitive processes acting.

The most basic level of information-processing is the matter of where we direct our Attention. We are only cognitively and emotionally affected by a particular aspect of our environment to the extent that we notice it, pay attention to it. A socially anxious person, for instance, tends to notice and attend to the expressions on people’s faces, scanning for any possible signs of disapproval; an alcoholic notices where the drinks are kept.

A particular focus of attention such as the above can then trigger relevant Self-talk/Automatic Thoughts. The socially anxious person might be thinking “They don’t like me, maybe I said something stupid”; the alcoholic might be thinking “I’ll never get through the evening without a drink.” Aaron Beck describes his discovery of Automatic Thoughts which “…appeared to emerge automatically and extremely rapidly…prior to experiencing the emotions” (1976, p. 33). Such automatic thoughts, which clients are normally unaware of, but which they can be trained to become more aware of, make sense of the troublesome feelings which immediately follow them. The socially anxious person’s automatic thoughts (ATs) will make them more anxious and self-conscious; the alcoholic’s AT’s will increase their craving.

However, we don’t all have the same ATs about the same situations, so our individual ATs must be influenced by certainly underlying Assumptions/Rules. These are less accessible to present-moment phenomenological awareness than ATs, but can be deduced from the way we habitually respond to situations, cognitively, emotionally and behaviourally. For instance, if the socially anxious person tends to agree with everything that other people say (like the Paul Whitehouse character in the 90s BBC TV sketch comedy “The Fast Show”), we can deduce that amongst their underlying assumptions/rules are things like “no one must dislike me” and “no one will dislike me if I don’t disagree with anyone.” Typical human Cognitive Distortions such as Emotional Reasoning, Black-and-White Thinking and Catastrophisation are also found at this level.

At a deeper level again we find our Core Beliefs/Schemas, as described in a previous blog (“A Client with a Past: Schema-based Case Formulation” - 2 June 2010):

Our earlier learning experiences leave us with deeply held ways of viewing the world, ourselves, and others, ‘templates’ through which we process current experience, and which therefore tend to be self-perpetuating and rigid in nature... These templates can be called Schemas; their contents (e.g. “I’m unlovable”, “Men can’t be trusted” etc) can be called Core Beliefs.

Core Beliefs are more unconditional than Assumptions, as the examples above show.

Evolutionary psychology sees human life, like that of any organism, as consisting of strategic attempts to maximise our success along various key axes, such as mating, care-giving, satisfying appetites etc… There is no definitive list (yet) of these motivational axes, but I have put together a list for myself for practical use in the therapy context, which probably covers the main areas… I find it useful to call these major themes in human life “THEMAs” (Typically Human Evolved Motivational Axes). Themas can be seen as analogous to schemas, but operating at an even deeper level, in the way that they structure our lives without us being aware of the fact most of the time. Schemas operate at the level where we are not generally aware how much they structure our experience as individuals. Themas operate at the level where we are not even generally aware how much they structure our experience as a species.

… I list below what I see as the main Themas using the mnemonic “PASTMARKS”.

Parenting

Attachment

Safety

Territory

Mating

Affiliation

Reciprocity

Kinship

Status

So there may be more to cognition than meets the eye – hopefully this has given you food for thought!